Provider Demographics
NPI:1073752119
Name:CANADA, CONNIE L (LM)
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:L
Last Name:CANADA
Suffix:
Gender:F
Credentials:LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13630 W DENTON ST
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:85340-3306
Mailing Address - Country:US
Mailing Address - Phone:623-547-0980
Mailing Address - Fax:623-535-4417
Practice Address - Street 1:13630 W DENTON ST
Practice Address - Street 2:
Practice Address - City:LITCHFIELD PARK
Practice Address - State:AZ
Practice Address - Zip Code:85340-3306
Practice Address - Country:US
Practice Address - Phone:623-547-0980
Practice Address - Fax:623-535-4417
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-12
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0157176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife